Is Overtreatment of Diabetes Widespread?

Ask anyone with diabetes what the most important goal of treating their condition is, and you’re likely to get the same answer from many of them: lowering blood glucose levels. And while it’s important to keep tabs on other measurements — such as blood pressure, body weight, and waist circumference — managing blood glucose levels remains the central goal of diabetes treatment.

But due to the risk of hypoglycemia (low blood glucose) that certain diabetes drugs such as insulin and sulfonylureas pose, in many cases it’s possible to go too far in lowering someone’s blood glucose levels — even if their HbA1c level (a measure of long-term blood glucose control) is still within the accepted range. This is particularly true in older adults, and according to a recent study, overtreatment in this age group may be widespread.

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Published earlier this month in the journal Diabetic Medicine, the study looked at 1,379 adults age 70 or older with Type 2 diabetes across 16 different doctor’s offices in Norfolk, England, who took either sulfonylureas or insulin. Nearly half of this group also had chronic kidney disease, and the median HbA1c level of the entire group was 7.5%, with no difference between those with and without kidney disease.

As noted in an article on the study at Diabetes.co.uk, researchers used HbA1c levels to estimate how many people in this group might have their diabetes overtreated, using 7.0% as the threshold. They found that 29.9% of the study group fell into this category, including 12.1% with an HbA1c level below 6.5%. People who took sulfonylureas were more likely than those who took insulin to have an HbA1c level below 7.0%, with 35% falling within this range, compared with 24% of those taking insulin. Among people who took both insulin and a sulfonylurea, 16% had an HbA1c level below 7.0%.

While these numbers may strike many people with diabetes as worthy goals or successful achievements, in older adults they may be less advisable than in the general population — especially if someone has another chronic health condition such as kidney disease, in which case the short-term risk of hypoglycemia could outweigh any long-term benefits of better glucose control. In fact, the American Diabetes Association, in its 2017 Standards of Medical Care in Diabetes, suggests an HbA1c goal of 7.5% for healthy older adults, and 8.0% for those with multiple chronic illnesses — both higher than for the general diabetes population.

Of course, it’s impossible to know from this study how widespread potential overtreatment of older adults is beyond its small population of participants. And even if similar data were available from across the entire United States, it still wouldn’t be clear exactly which cases indicate overtreatment, and which ones just show healthy adults with excellent blood glucose control. To more accurately estimate overtreatment, any study would probably need to include episodes of hypoglycemia in its calculation.

If you’re an older adult, do you think your doctor is adequately taking your age and health condition into account when setting your blood glucose and HbA1c goals? Have you experienced hypoglycemia regularly, and if so, has your doctor adjusted your treatment in response? Would you like to relax your blood glucose control somewhat if you thought you could do so safely, or have you already? Leave a comment below!

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barbara

When your nephrologists says you need to get the HbA1C under 6, as well as your internist and cardiologist, your comments seem very strange. Lower the HbA1C the higher the hemoglobin level for patients with kidney disease, the better off the patient. Dealing with chronic anemia because of higher HbA1C is no fun. So should people believe you or their nephrologists, internists and cardiologists?

RAWLCM

You ask a really good question and I wish there was a perfect answer. The truth is, no one really understands diabetes. Researchers learn new things every day. The role of genetics has barely been scratched, as have environmental factors. There is still so much to be learned. The treatments that patients are given are based on the best understanding of the attending physician(s), and ideally are decided in cooperation with the patient. Like many, I see several specialists. My primary and endocrinologist are pretty much in agreement about what I need, but my cardiologist disagrees and so does my nephrologist. They have other priorities and goals in mind. Obviously my cardiologist is thinking more about my heart than my pancreas. In the end, my clinic believes it’s a decision that the patient ultimately makes. In my case, and HbA1C of 7 or lower and everyone feels good about it. As they say in the auto ads, your mileage may vary. I firmly believe each patient is unique and needs a specifically tailored treatment plan. Under 6 may be just right for you. If I were to give you any advice at all it would be “Talk to your providers and ask them *why* this specific number is your goal.”

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